Case Study

Obstetric Hemorrhage & Post Partem Hysterectomy

Resham Bhargava v. Super Specialty Hospital, Mata Chanan Devi Hospital, Consumer Case No. 2240 of 2016. Decided By The Hon’ble NCDRC, New Delhi On  07 Jan 2020

Facts: Resham Bhargava, about 27 years of age during her first pregnancy visited O.P. No. 1 at New Delhi, O.P. No. 3 Gynaecologist examined her and advised her for regular antenatal check-up (ANC). Her periodic blood tests and ultrasound were performed and the reports were found normal.  On 10.07.2016, O.P. No. 3 admitted the patient in O.P. No. 1 hospital.  On the next day at 11.15 a.m. O.P. No. 3 told her that due to presence of bone in delivery pathway, normal delivery was not possible and therefore she needs surgical delivery (Lower Segment Caesarean Section – ‘LSCS’). Unwillingly the patient herself and her husband agreed for LSCS and signed some papers under force of O.P. Nos. 2 & 3.  The baby girl was delivered by LSCS.

However, while shifting the patient from operation theatre to the ward, the patient experienced severe pain, weakness and blurred vision. After few minutes the patient was unable to breath and immediately O.P. No. 3 doctor was called who examined the patient and told her husband that such condition might be due to bleeding inside and there was need to open the abdomen again. The operation consumed several hours, but her husband was kept in dark about the happenings. It was when the patient’s husband threatened to take legal action against the Opposite Parties, only then the doctor disclosed that uterus of the patient was removed and approx. 1.5 litres of blood was present in the abdomen. It was alleged that patient was operated with the help of more than 10 doctors. After the second surgery the patient was kept in ICU from 11.07.2016 to 17.07.2016.  The patient paid a huge amount of Rs. 2,10,000/- towards the medical bills.  The complainant / patient alleged that due to removal of the uterus, she lost her chance to give birth to a child in future and it was due to carelessness and gross negligence of the Opposite Parties.  She filed a complaint against the Opposite Parties and prayed for compensation of Rs. 1,10,00,000/-.

Observations: Discussion on “i) whether LSCS was performed hastily without consent”: The patient during ANC period was under observation of O.P. Nos. 2 & 3 at O.P. No. 1 hospital.  As per the initial assessment and plan the expected date of delivery was 11.07.2016. The periodic ANC follow-up with blood and Ultra Sonography (USG) investigations were normal.  On careful perusal of the medical record, the final diagnosis was ” Primi gravida at 38 weeks + 4 days POG with Intrahepatic Cholestasis of pregnancy (IHCP) with mildly deranged LFT”. Therefore, because of IHCP, the patient was admitted for the induction of labour. On examination the cervix was uneffaced, vertex at -3, therefore, Cerviprime gel was instilled and augmentation of labour was done with Syntocinon drip but there was no improvement in bishops score. The induction of labour was not successful, therefore after informed consent LSCS, was performed. Thus, the allegation about hasty decision to perform LSCS is not sustainable.

Discussion on “ii) whether hysterectomy was caused due to the carelessness of the opposite parties”: In this context, we have perused the operative notes dated 11.07.2016 (2nd operation – hysterectomy).

On a bare perusal of the operative notes, it is clear that the patient developed atonic PPH after LSCS delivery. After delivery, the uterus did not contract – regain its size. The uterus remained flabby. Despite giving uterotonics and applying the sutures, the bleeding P/V was (3+). It was life saving emergency, therefore, after informed consent the subtotal hysterectomy was performed by O.P. No.3. The patient was given transfusion of blood and its components (PRBC, FFP, Platelets) to correct the hypovolemic shock. Regarding Post-Partum Hemorrhage and atonic uterus, we have perused standard medical books in Obstetrics and Gynecology viz. Shaw’s book of Gynecology and William’s book of obstetrics. The post-partum hemorrhage (PPH) or bleeding after childbirth is a well-known.  It is a dreaded and leading cause of maternal morbidity and mortality worldwide even in the best centers. The process of child birth can take such a lethal turn. Only a qualified obstetrician can understand uterine atony or failure of the uterus to contract after childbirth as the most common cause. It can lead to rapid and severe haemorrhage shock, DIC, multiple organ failure and finally death. In the instant case, as per the medical record, patient was under observation after LSCS delivery. Patient developed hypovolemic shock in post-operative period with sudden hypotension and emergency resuscitation was done. The patient developed atonic uterus, it was managed by a qualified obstetrician with great technical expertise. Patient had bleeding PV (3+), uterus was relaxed i.e. atonic PPH. Doctor performed vigorous manual massage. The USG revealed uterus filled with clots and haemoperitoneum (+).  Based on the finding and as a last resort to stop bleeding, O.P. No. 3 performed emergency laparotomy with the help of a Surgeon. The emergency hysterectomy, as a standard treatment, was performed to save the life of the patient. The precious life of a mother and baby was saved at O.P. No. 1 hospital and on 18.07.2016, the patient was discharged in satisfactory condition. To know more about emergency postpartum hysterectomy we have gone through William’s book of obstetrics and medical literature and research papers on the subject.

Held: Considering the medical record and the relevant medical literature it is clear that, firstly the decision of Opposite Parties No. 2 & 3 was correct to perform LSCS, because the patient was primi-gravida at 38 weeks + 4 days and having developed Intrahepatic Cholestasis of pregnancy (IHCP) with mildly deranged LFT.  We note, the patient was admitted for induction of labour but it was failed therefore LSCS was performed after taking the informed consent. A female baby was delivered without any complications. It was neither deviation from the standard practice nor negligence.

Secondly, after delivery, the patient developed atonic PPH. The patient was given proper utero-tonics and vitamin K injection but the uterus remained flabby. For correction of hypovolemic shock   IV fluids, 2 units whole blood, 2 units PRBC, units FFP and 1 unit platelet aphresis were transfused. In spite of utero-tonics administration and B-Lynch brace

Concealed obstetric hemorrhage

suture being applied there was bleeding P/V (3+). Therefore, the decision of subtotal hysterectomy was taken by O.P. No. 3. The same was informed to the husband and family members of the patient as it was for saving the life of the patient. The emergency caesarean hysterectomy was performed with the help of a surgeon, Dr. J. S. Gulati. In our considered view this decision of O.P. No. 3 was correct and the emergency was handled as per standards.

Based on the foregoing discussion, relying on the standard medical literature, it is not feasible to attribute negligence / deficiency in treatment given in both performing LSCS and the emergency exploratory laparotomy for subtotal hysterectomy, it is difficult to conclusively establish medical negligence / deficiency in service. The complaint fails, and is dismissed.   On sympathetic and humanitarian grounds, the Registry of this Commission is directed to refund the fee of Rs. 5,000/- deposited by the complainant at the time of filing of the complaint, after the due verification.

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